Nursing Elites

1. Following a total hip arthroplasty, what intervention should the healthcare provider implement for the client?

• A. Place a pillow between the client's legs.
• B. Elevate the head of the bed to 45 degrees.
• C. Position the client on the operative side.
• D. Keep the client’s legs adducted.

Correct answer: A

Rationale: Placing a pillow between the client's legs is crucial post hip arthroplasty surgery to prevent hip dislocation. This intervention helps maintain proper alignment and prevents legs from crossing midline, reducing the risk of hip prosthesis dislocation. Elevating the head of the bed to 45 degrees, positioning the client on the operative side, or keeping the client's legs adducted are not recommended postoperative interventions for a total hip arthroplasty, as they can increase the risk of complications and compromise the surgical site.

2. A healthcare professional is supervising a newly licensed colleague who is preparing to administer an intramuscular injection. Which of the following actions by the newly licensed colleague requires intervention?

• A. Selecting a 25-gauge needle
• B. Administering the injection at a 45° angle
• C. Using the ventrogluteal site for the injection
• D. Aspirating for blood return before injecting the medication

Correct answer: B

Rationale: The correct answer is B. Administering an intramuscular injection at a 90° angle is essential for proper medication delivery into the muscle tissue. Injecting at a 45° angle is incorrect for intramuscular injections and is typically used for subcutaneous injections where the needle is inserted into the fatty tissue layer beneath the skin. Choice A is correct as selecting a 25-gauge needle is appropriate for an intramuscular injection. Choice C is also correct as the ventrogluteal site is a suitable site for intramuscular injections. Choice D is correct as aspirating for blood return is a necessary step to ensure the needle is not in a blood vessel before injecting the medication.

3. A healthcare professional is preparing to administer an intramuscular (IM) injection to a client. Which of the following actions should the healthcare professional take?

• A. Use a 1-inch needle.
• B. Insert the needle at a 45-degree angle.
• C. Aspirate before injecting the medication.
• D. Administer the injection in the deltoid muscle.

Correct answer: C

Rationale: Aspirating before injecting the medication is a crucial step in IM injections to check for blood return, ensuring that the needle is not in a blood vessel. This technique helps prevent accidental intravascular injection of the medication, reducing the risk of complications such as inadvertent intravenous administration of the substance.

4. When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?

• A. Tremors
• B. Urine retention
• C. Kussmaul respirations
• D. Bradypnea

Correct answer: C

Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood. Tremors (Choice A) are not typically associated with DKA. Urine retention (Choice B) is not a common finding in DKA; in fact, clients with DKA often have polyuria due to the osmotic diuresis caused by high blood glucose levels. Bradypnea (Choice D), which is abnormally slow breathing rate, is not a characteristic finding in DKA where the respiratory rate is usually increased to compensate for metabolic acidosis.

5. A client with a new diagnosis of anemia is being taught about dietary management. Which of the following statements should be included in the teaching?

• A. You should increase your intake of foods high in iron.
• B. You should decrease your intake of foods high in calcium.
• C. You should avoid foods that contain gluten.
• D. You should increase your intake of high-fat foods.

Correct answer: A

Rationale: The correct answer is A: 'You should increase your intake of foods high in iron.' This statement should be included in the teaching because increasing intake of foods high in iron is essential for managing anemia. Iron is a key component for producing hemoglobin, which carries oxygen in the blood. By increasing iron-rich foods like leafy greens, red meat, and fortified cereals, the client can help improve their hemoglobin levels and overall health. Choices B, C, and D are incorrect. Decreasing intake of foods high in calcium is not necessary for anemia management; avoiding foods that contain gluten is relevant for individuals with gluten sensitivity or celiac disease, not anemia; and increasing intake of high-fat foods is not recommended for managing anemia.

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